Prepared by: Mary Nol Munoz Creollo BSN-II Regular

A. Frequency of Prenatal Visits

Month 1-7 Frequency of Visit Once a month

8-9
10 Post term

Twice a month
Every week Twice a week

1. PRECONCEPTUAL VISIT hemoglobin level and blood type (including the Rh factor) can be determined minor vaginal infections such as those arising from Candida or Chlamydia can be corrected to help ensure fertility woman can be counseled on the importance of a good protein diet, adequate intake of folic acid and early prenatal care if she does become pregnant

PRECONCEPTION
- defined as the extent of understanding conveyed about maternal health prior to conception to ensure a healthy pregnancy

PRECONCEPTION COUNSELING
- defined as screening and providing information and support to individuals of childbearing age before pregnancy to promote health and reduce risks

CHOOSING A HEALTH CARE PROVIDER FOR PREGNANCY AND CHILDBIRTH

Various options in choosing a health care provider:

Prenatal clinic Health care provider Nurse-Midwife An Obstetrician Family Practitioner

HEALTH ASSESSMENT DURING THE FIRST PRENATAL VISIT

Prenatal care is important because lack of it is associated with the birth of preterm infants and various complications for the woman. Major causes of death during pregnancy today are the following: 1. ectopic pregnancy 2. hypertension 3. hemorrhage 4. embolism 5. infection 6. anesthesia-related complications ( intrapartum cardiac arrest )

WHAT TO EXPECT ON THE FIRST PRENATAL VISIT?

The first prenatal visit is the most comprehensive of all visits. The medical history will be taken, a complete physical examination done, and certain tests and procedures ( urinalysis, blood test, Pap smear, etc ) will be performed.

WHAT TO EXPECT ON THE SECOND PRENATAL VISIT?

The physician will check the following: 1. weight and blood pressure 2. urine for sugar and protein 3. hands and feet for swelling and legs for varicose veins

WHAT TO EXPECT ON THE THIRD TO EIGHT PRENATAL VISIT?

The physician will check the following:
1. weight and blood pressure 2. urine for sugar and protein 3. fetal heartbeat 4. size and shape of uterus, by external palpation to see how it correlates to estimated date of delivery ( EED ) or due date 5. height of fundus ( top of the uterus ) 6. hands and feet for swelling and legs for varicose veins 7. questions or problems you want to discuss

WHAT TO EXPECT ON THE NINTH PRENATAL VISIT?

After about 36th week, the mother should see a doctor weekly:
1. weight ( gain generally slows down or ceases ) and blood pressure ( it may be higher than it was at the mid pregnancy) 2. urine for sugar and protein 3. fetal heartbeat 4. fetal size, presentation ( head or buttocks, first? ), position ( facing to the front or back? ) and descent 5. hands and feet for swelling and legs for varicose veins 6. cervix ( by internal examination ) for effacement and dilation 7. frequency and duration of Braxton Hicks Contractions

B. DANGER SIGNS OF PREGNANCY

SYMPTOM
1. vaginal bleeding 2. pelvic and abdominal pain 3. persistent back pain

POTENTIAL PROBLEM
miscarriage, abruptio placenta, placenta previa miscarriage, ectopic pregnancy, and abruptio placenta miscarriage, preterm labor

4. swelling of the hands and pregnancy-induced hypertension face (PIH ), eclampsia

5. persistent vomiting - once or twice-daily vomiting is not uncommon during the first trimester of pregnancy, however persistent or frequent vomiting is not normal, vomiting is not normal, vomiting that continues past the 12th week of pregnancy is also extended vomiting. Persistent or extended vomiting depletes the nutrients/ nutritional supply available to a fetus and is danger to the pregnancy. 6. chills and fever - may indicate an intrauterine infection, a series complication for both a women and a fetus 7. gush of clear fluid from the vagina - means that membranes have ruptured and mother and a fetus are both threatened, because the uterine cavity is no longer sealed against infection

POTENTIAL PROBLEM:
- preterm labor, rupture of membranes and miscarriage

8. pregnancy-induced hypertension ( PIH ) - refers to a potentially severe and even fatal elevation of blood pressure that occurs during pregnancy Signs and symptoms that PIH is developing: 1. rapid weight gain ( over 2lb per week in the second trimester, and 1lb per week in the third trimester ) 2. swelling of the face and fingers 3. flashes of light or dots before the eyes 4. blurring vision 5. severe, continuous headache 6. decrease urine output 9. increase/decrease in fetal movement - unusual decrease or increase in movement suggests that a fetus is responding to the need for oxygen

C. NUTRITION
RECOMMENDED WEIGHT GAIN DURING PREGNANCY

- 11.2 to 15.9kg ( 25 to 35 lb ) currently recommended as an average weight gain in pregnancy

NORMAL PREPREGNANCY BMI:

underweight normal weight overweight obese

- under 18.5 - 18.5 24.9 - 25.0 29.9 - above 30.0

Calories Essential to supply energy for: 1. Increased metabolism 2. Utilization of nutrients 3. Protein sparing used for growth of fetus and development of structures required of pregnancy including placenta, amniotic fluid and tissue growth Protein Essential for: 1. Fetal tissue growth 2. Maternal tissue growth including uterus and breast 3. Development of essential pregnancy structures 4. Formation of RBC and plasma proteins 5. Inadequate protein intake has been associated with onset of PIH
Calcium Phosporus Esential for: 1. Growth and development of fetal skeleton and tooth buds 2. Maintenance of mineralization of maternal bone and teeth 3. Adequate calcium intake prevents PIH Vit. D (Essential for Calcium Absorption)

300 calories/d ay

No more than 30% of fat Whole grains, vegetables, and fruits

60mg/day

Lean meat, poultry, fish Eggs, cheese, milk Dried beans, lentils, nuts Whole grains

1200mg/day

10mcg/day

Dairy Products: milk, yogurt,ice cream, cheese, egg yolk, Whole grains, tofu, green leafy vegetables,canned salmon and sardines with bone,orange juice Vit. D Fortified milk, margarine, egg yolk, butter liver and sea foods Liver, red meat, fish, poultry eggs, whole grains cereal and breads,dark green leafy vegetables, legumes, nuts and drier fruits Liver meats,Shell fish, Eggs, milk cheese,Whole grains, legumes and nuts

Iron Essential for: 1. Expansion of blood volume and RBC production 2. Establishment of fetal iron stores for first few months of life Zinc Essential for: 1. Formation of the enzyme 2. Prevention of the formation of congenital malformation Folic Acid, Folacin Folate Essential for: 1. Formation of RBC, Prevention of anemia 2. DNA synthesis and cell formation, help in the prevention of neural tube defect, abortion and abruptio placenta

30mg/d

15mg/d

400mcg/d

Liver, kidney, lean beet veal, Dark green leafy vegetables, brocolli, asparagus artichokes, legumes, whole grains and peanut

COMPONENTS OF HEALTHY NUTRITION FOR THE PREGNANT WOMAN

CALORIE NEEDS
The DRI of calories for women of childbearing age is 2,200, for pregnant women should meet a total caloric intake of 2,500 kCal. In addition to supplying energy for a fetus and placenta, this increase provides calories to: 1. sustain an elevated metabolic rate from increase thyroid function 2. increase workload from the extra weight a woman carry An adequate intake of carbohydrates may lead to protein breakdown for energy, depriving a fetus of essential protein and possibly resulting in KETOACIDOSIS- a possible cause of fetal and neurologic disorders

WHERE TO FIND IT: carrot sticks / cheese crackers

PROTEIN NEEDS
The DRI for protein in women is 44 to 50 g., for pregnant women should be 60 g daily. Extra protein is best supplied by meat, poultry, fish, yogurt, eggs, and milk because in the forms contains all nine essential amino acids ( complete protein ). The protein in non-animal sources does not contain all essential amino acids ( incomplete protein ). COMPLEMENTARY PROTEINS - proteins that when cooked together provide all essential amino acids eg. beans and rice legumes and rice beans wheat A woman with high cholesterol levels ( hypercholesterolemia ) probably should not eat more than 2 to 3 eggs per week because of high cholesterol content of eggs. Milk is rich source of protein.

FAT NEEDS
Fat should be limited to no more than 30% of daily calories. Use high fat foods such as butter, cream (sour), salad dressings, and gravies sparingly. Also try to limit sweets. Only linoleic acid, an essential fatty acid necessary for new cell growth.

FLUID NEEDS
Extra amounts of H2O are needed during pregnancy to promote kidney function because a woman must excrete waste products for two. Two glasses of fluid daily over and above a daily quart of milk is a common recommendation (total of 6 glasses)

FIBER NEEDS
Constipation can occur during pregnancy from slowed peristalsis due to the pressure of the uterus on the intestine. Eating fiber-rich foods, foods consisting of parts of the plants cell wall resistant to normal to normal digestive enzymes of the small intestine, such as broccoli and asparagus are natural way of preventing constipation, because the bulk of the fiber left in the intestine aids evacuation. Advantages of foods rich in fiber: 1. lowering cholesterol levels 2. may remove carcinogenic contaminants from the intestine Encourage women to eat plenty of: fresh fruits green leafy vegetables

ESSENTIAL VITAMIN/ MINERAL Vitamin A and Beta Carotene (800 mcg) Vitamin D (10 mcg)

WHY YOU NEED IT

Helps mom and babys cells grow and stay healthy.

WHERE YOU FIND IT

Liver, milk, eggs, carrots, spinach, green & yellow vegetables, broccoli, potatoes, pumpkin, yellow fruits and cantaloupe. Milk, fatty fish, egg yolks, and a little sunshine.

Helps develop babys skeletal system. Prevents rickets.

Vitamin E (800 mcg)

Helps baby grow and develop at a normal rate.

Vegetable oil, margarine, wheat germ, nuts, spinach, and fortified cereals. Citrus fruits and juices, bell pepper, green beans, strawberries, papaya, potatoes, broccoli, and potatoes. Whole grain, fortified cereals, wheat germ, organ meats, eggs, rice, pasta, berries, nuts, legumes, an pork. Meats, poultry, fish, dairy products, fortified cereals, and grains.

Vitamin C (60-85 mg)

An antioxidant that protects tissues from damage and helps moms body absorb iron. Raises moms energy level, and regulates mom and babys nervous system. Maintains energy, good eyesight, and healthy skin from mom and baby.

Thiamin/ B1 (1.5 mg)

Riboflavin/ B2 (1.6 mg)

Niacin/ B3 (2 mg)

Maintains energy levels, regulates the nervous system, and helps mom and baby have beautiful skin. Helps calm moms tummy.

High protein foods, breads, meat, fish, eggs, and peanuts.

Pyridoxine/ B6 (450 mg) Folic acid/ Folate (600 mcg)

Chicken, fish, liver, banana, beans, brown rice, oats, and walnuts. Oranges, pasta, broccoli, and spinach.

Helps support placenta, and prevents spina bifida and other neural tube defects.

Calcium (1,200-1,600 mg)

Iron (27-30 mg)

Creates strong bones for mom and baby.

Helps in production of hemoglobin for baby. Prevents anemia, low birth weight, and premature delivery. Helps in production of amino acids, the building blocks for babys cells. Repairs mom cells. Low levels could mean longer labor, LBW and health problems

Yogurt, milk, cheddar, calcium fortified foods like soy milk.

Beef, pork, dried fruits, and beans.

Protein (60 mg)

Most animal foods, meat, veggies burgers, and nuts. Red meats, oysters, dairy products and poultry.

Zinc (15 mg)

FOODS TO AVOID IN PREGNANCY

1.FOODS WITH CAFFEINE - 8 cups of coffee -associated with an rate of still birth If a woman has difficulty omitting these foods from the diet, she should reduce the amount of caffeine she ingests by modifying the preparation. eg. 1. instant coffee less cafeine than brewed coffee 2. percolated coffee no caffeine 2. ARTIFICIAL SWEETENERS - used to improve the taste and limit the caloric content of foods *Pregnant women should reduce the intake of artificial sweeteners.
NOTE: The use of saccharine is not recommended during pregnancy because it is eliminated slowly from the fetal bloodstream. 3. WEIGHT LOSS DIETS - reducing diet and caloric restrictions are contraindicated during pregnancy because they may lead to fetal acidosis and poor growth

D. SEXUAL ACTIVITY
Caution about male oral female genital contact, because
accidental air embolism has been reported from this act during pregnancy. Women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of the pregnancy when a previous miscarriage occurred.

D. SEXUAL ACTIVITY
Caution about male oral female genital contact, because
accidental air embolism has been reported from this act during pregnancy. Women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of the pregnancy when a previous miscarriage occurred.

NOTE: No sexual restrictions during pregnancy!!!

Early in pregnancy, a woman may experience a decreased desire for coitus resulting from the increased estrogen level in her body. Breast tenderness may limit a usual pattern of sexual arousal. Increase in pelvic congestion from the additional uterine blood supply, most women noticed increased clitoral sensation. Some women may experienced orgasm for the first time during pregnancy because of the increased pelvic congestion. Position will do: side by side position (a woman in a superior position may be comfortable As vaginal secretions change, a woman may find a water-soluble lubricant helpful. If she begins to experience discomfort from penile penetration, mutual masturbation/ female oral male genital relations might be satisfying to both partners

-Exercise during pregnancy is important to prevent circulation stasis in the lower extremities. -Can also offer a general feeling of well-being. -Extreme exercise has been associated with a lower birth rate. -Well nourished women should exercise during pregnancy every day for 30 consecutive minutes. Exercise program should consists:

E. EXERCISE

-Exercise during pregnancy is important to prevent circulation stasis in the lower extremities. -Can also offer a general feeling of well-being. -Extreme exercise has been associated with a lower birth rate. -Well nourished women should exercise during pregnancy every day for 30 consecutive minutes. Exercise program should consists: 5 minutes warm up exercises 20 minutes an active stimulus phase 5 minutes cool-down exercises

E. EXERCISE

-Exercises that exercise huge muscle groups rhythmically such as walking are BEST. -Both pregnant & nonpregnant women should exercise at 70% to 85% of their maximum heart rate. -A planned exercise program may have a long term benefits such as: 1. lowered cholesterol level 2. reduced risk osteoporosis 3. energy level 4. maintenance of healthy body weight 5. risk of heart disease 6. increased self-esteem & well being

-Swimming is a good activity for pregnant women and like bathing, is not contraindicated as long as the membranes are intact. -It may help relieve back ache during pregnancy. -Long distance swimming or any other activity carried out to a point of extreme fatigue should be avoided. -High impact aerobics is contraindicated because this can be strenous to both pelvic and knee joints, may lead to hyperthermia for the mother and fetus. -WALKING is the best exercise during pregnancy, and women should be encouraged to take a walk daily unless inclement weather, many levels of stairs or an unsafe neighborhood are contraindications.

-Swimming is a good activity for pregnant women and like bathing, is not contraindicated as long as the membranes are intact. -It may help relieve back ache during pregnancy. -Long distance swimming or any other activity carried out to a point of extreme fatigue should be avoided.
-High impact aerobics is contraindicated because this can be strenous to both pelvic and knee joints, may lead to hyperthermia for the mother and fetus. NOTE:
Elevation of maternal body temp. by 2C for at least 24 hrs can cause range of developmental mental defects. Use of hot tubs & saunas after workouts longer than 15 mins is contraindicated, however, on the chance these could raise the internal fetal temp

F. CHILDBIRTH PREPARATION
1.PERINEAL & ABDOMINAL EXERCISES

A. Tailor Sitting B. Squatting C. Pelvic Floor Contractions (Kegel Exercises) D. Abdominal Muscle Contractions E. Pelvic Rocking

A. Tailor Sitting
- done to stretch the perineal muscles without occluding blood supply to the lower legs - a woman should not put one ankle on top of the other but should place one leg in front of the other - as she sits in this position, she should gently push on her knees toward the floor until she feels her perineum stretch Good position to: watch television, read, and talk to friends - good to plan on sitting in this position for at least 15 minutes everyday

B. SQUATTING - helps to stretch the muscles of the pelvic floor and can be useful position for 2nd stage of labor, practice this position for about 15 minutes a day

C. PELVIC FLOOR CONTRACTIONS - Designed to strengthen the

pubbococcygeal muscles. Each separate exercise and should be done about 3 times a day - Such perineal muscle-strengthening exercises will be helpful in the postpartum period to reduce pain and promote perineal healing. - Have long term effects of increasing sexual responsiveness and helping prevent stress incontinence

D. Abdominal Muscle Contractions

- help strengthen muscles in the abdomen and help restore abdominal tone after pregnancy - strong abdominal muscles can also contribute to effective 2nd stage pushing during labor - she can repeat the exercise as often as she wishes during the day

E. PELVIC ROCKING
- helps relieve back ache during pregnancy and early labor by making the lumbar spine more flexible Variety of positions: on hands and knees lying down sitting standing - The woman hollows her back and then arches it. - 5 times a day to relieve back pain and make herself more comfortable

METHODS OF PAIN MANAGEMENT

1. The Bradley (Partner-Coached) Method 2. The Psychosexual Method 3. The Dick-Read Method 4. The Lamaze Method

1. The Bradley (Partner-Coached) Method Originated by Robert Bradley (1981), based on the premise that childbirth is a joyful natural process and stresses the important role of a womans partner during pregnancy, labor and newborn period. a woman performs muscle toning exercises and limits/ omits foods that contain preservatives animal fats, or high salt content pain is reduced in labor by abdominal breathing

2. THE PSYCHOSEXUAL METHOD

developed by Shiela Kitziger in England during 1950s

stresses that pregnancy, labor and birth, and the

early newborn period are important points in a womans life cycle includes a program of conscious relaxation and levels of progressive breathing that encourages a woman to flow with rather than struggle against contractions

4. THE LAMAZE METHOD based on the theory that through stimulus-response conditioning women can lead to use controlled breathing to reduce pain during labor originally termed as PSYCHOPROPHYLACTIC METHOD focuses on preventing pain in labor (prophylaxis) and by used of mind (psyche) popularized by a French Physician, Ferdinand Lamaze

3. THE DICK-READ METHOD based on the proposed by Grantly Dick-Read, an English Physician the premise is that fear leads to tension which leads to pain if one can prevent this chain of events from occurring, or break the chain between fear and tension/ tension and pain, then one can reduced the pain of contractions a woman achieves relaxation and reduced pain by focusing on abdominal breathing during contractions

SIX MAJOR CONCEPTS

1. labor should begin on its own, not be artificially induced
2. women should be able to move about freely throughout the labor, not be confined to bed 3. women should receive continuous support during labor 4. no routine interventions such as intravenous fluids are needed 5. women should be allowed to assume a non-supine position for birth 6. mother and baby should be housed together following birth, with unlimited opportunity for breast feeding

G. DIFFERENT METHODS OF DELIVERY

Vaginal delivery is the most common and safest type of childbirth. When necessary in certain circumstances, forceps (instruments resembling large spoons) may be used to cup your baby's head and help guide the baby through the birth canal. Vacuum delivery is another way to assist delivery and is similar to forceps delivery. In vacuum delivery, a plastic cup is applied to the baby's head by suction and the health care provider gently pulls the baby from the birth canal. Although vaginal delivery is the most common and safest type of delivery, sometimes cesarean delivery is necessary for the safety of you and your baby.

1. Birthing Chair: semi fowlers position 2. Birthing Bed: dorsal recumbent position 3. Squatting Position: facilitate descent and relieves low back pain 4. Leboyers Method: to prevent trauma to the baby A) Requirements: a. Darkened Room b. Quiet and calm environment c. Room Temperature d. Soft Music e. Warm bath for the baby after delivery
5. Birth Under water: common practice in USA, Latin America, Japan, and Scandinavian Region

VAGINAL DELIVERY

Caesarian Delivery
Caesarian birth, or birth accomplished through an abdominal incision into the uterus, is one of the oldest types of surgical procedures known. The word caesarian is derived from the Latin word caedore, which means to cut. At one time, there was a popular belief that Julius Caesar was born by caesarian birth and the procedure was named for him. The term caesarian birth, rather than caesarian delivery, is used to accentuate that this is a birth more than a surgical procedure.

A baby born in a caesarian delivery

A cesarean delivery may be necessary if one of the following complications is present: Your baby is not in the head-down position. Your baby is too large to pass through the pelvis. Your baby is in distress. Most often, the need for a cesarean delivery is not determined until after labor begins. Once a woman has had a cesarean delivery, future deliveries are often also done by cesarean. That's because surgery done on the uterus increases the risk of it rupturing during a future vaginal delivery.